What is a Tracheostomy?
A tracheostomy is a surgical procedure carried out to make a hole through a person’s neck into the windpipe. A tracheostomy tube passes through the hole into the trachea, and the patient breathes through it. The alternative name is ‘tracheotomy’.
A couple of Greek physicians first penned down the alternative breathing surgery, ‘Galen and ‘Aretaeus’. The term tracheostomy is taken from the Greek words’ trachea’ meaning windpipe, ‘stoma’ meaning mouth or hole and ‘tome’, which means to cut. The alternative name for the tracheostomy medical definition is ‘tracheotomy’.
What is the Purpose?
The tracheostomy causes that could trigger medical help are listed as follows:
- Block in the trachea
- Congenital abnormalities of the trachea
- Larynx’ or voicebox injury
- Extension of ventilator support
- Burns suffered from breathing in corrosive substances
- Obstructive breathing problems during sleep
- Burns on the face or facial surgery
- Critical facial or neck trauma
- Severe diseases involving the lungs
- Paralysis of the vocal cords
- Varying reasons for coma
- Bad cases of infection
- Cancers or tumours of the neck or head
- Anaphylactic shocks
Children who suffer from complications as follows may need a tracheostomy:
- Very small or blocked airway.
- Excess mucus in the trachea
- Breathing dependency on a ventilator
- In aspiration
What is a Tracheostomy Tube?
It is a special curved tube installed within a stoma useful in a tracheostomy procedure. It consists outer cannula, a tracheostomy inner cannula and a prosthetic device.
- The neck plate is an extension of the outer cannula and contains holes for accommodating the Velcro strap or other tying straps.
- The outer cannula is an opening device that keeps the tracheostomy open.
- The inner cannula is accommodating within the outer cannula, and it is periodically opened up for cleaning purposes and fixed with the help of a lock system.
- The obturator helps in the insertion of the tracheotomy tube inside the trachea.
Tracheostomy tubes include cuffed tracheostomy tubes, fenestrated tracheostomy tubes, metal tracheostomy tubes, etc. Ideally, maintain a tracheostomy cuff pressure of 20 to 25 cm water with the cuffed tube.
Various types of tracheotomy anatomy procedures are performed depending on the patient’s condition. The surgeon gives general anaesthesia to patients. But sometimes, when the trachea is heavily blocked, an awake tracheostomy is performed, and the doctor provides local anaesthesia.
According to the site of the procedure, there are three tracheostomy level types.
- High Tracheostomy is performed at 2 cm over the Thyroid gland at the first ring of the trachea.
- Mid Tracheostomy is performed either at the second or third ring of the trachea or the Isthmus region of the Thyroid gland. When clamping, retracting, or ligating the Thyroid gland, the patient has to undergo surgery.
- Low Tracheostomy is conducted at the fourth ring of the trachea below the Thyroid Isthmus.
According to the time duration, there are two types.
- Temporary Tracheostomy is done when the doctor removes the tracheostomy tube in a short time.
- Permanent Tracheostomy is performed when inserting a tracheostomy tube for an indeterminate period. Moreover, it will execute in a Laryngectomy procedure.
Mini tracheostomy involves the cricothyroid membrane, opening up an airway passage in emergency cases. Hence it is also called ‘Cricothyrotomy’. Insert a large intravenous catheter via the cricothyroid membrane during the Cricothyroid needle puncture.
Bjork flap tracheostomy began as an alternate solution to the single insertion incision. Here, make a U-shaped cut between the trachea’s third, fourth or second rings. It forms a flap secured to the tracheostomy lumen by suturing it to the skin.
The tracheostomy procedure steps involved in Open Surgical Tracheotomy (OST) are listed below:
- After giving anaesthesia, the surgeon cuts through the neck region below the larynx.
- This cut or stoma is big enough to insert a tracheostomy tube into the trachea. It may be a transverse or vertical cut over the suprasternal notch. Place the tracheal hook upon identifying the Cricoid cartilage and separating the muscles and subcutaneous tissues.
- An insertion happens in the trachea by removing a ring from the tracheal cartilage or between the different cartilage rings. Then a vertical cut through rings creates a ‘cruciate incision.
- The tracheotomy ventilator is then attached to the tracheostomy tube and administrates the oxygen.
The doctor performs percutaneous dilatational tracheostomy at the bedside and avoids paediatric patients. It involves the following steps:
- After sedation, the surgeon makes a 2 cm cut under the cricoid border.
- The trachea is opened and exposed after dissection.
- The Isthmus of the Thyroid gland directs downwards.
- A bronchoscope having an attached camera is inserted through the tube.
- Cutting of the trachea between the second and third rings.
- Inserting of tracheostomy tube after dilatation.
Prepare for a Tracheotomy
During a pre-planned tracheostomy procedure, the patient needs to fast. Get to know the time you’ll spend in the hospital. Understand the complications. Be ready with supplies needed after the surgery. Stop smoking.
Surgical Procedure During Tracheostomy
Tracheotomy Suctioning helps avoid replacing the tracheostomy inner cannula and tackle occlusions. The tracheotomy care procedure suctions out any secretions in the stoma. The tracheostomy suctioning time is limited to just 10 to 20 seconds with the tracheostomy suction machine. The pressure to be maintained is between 80 to 120 mm Hg during the tracheostomy suctioning steps. Before any suctioning, there are clinical risks to be considered, like hypoxia, infection, lung collapse, tissue damage, etc.
Post-op Procedure After Tracheostomy
The most important tracheostomy care nursing procedure is to maintain the position. Tracheostomy tube care is of utmost importance after surgery, and the tracheostomy tube has to be changed every month or three months. This tracheostomy tube removal has to be performed by an ENT doctor, respiratory therapist, or trained nurses.
The tracheostomy has to be kept clean and free from infection. It indicates a foul smell or discharge. A mirror can help take out dressings or replace them. Cleaning the stoma once a day by wiping the cannula with a saline solution is needed. Uses dry gauze to clean out dried particles or mucus.
Risk factors Involved in Tracheostomy
There are some risk factors to consider after the tracheostomy operation, and they are listed as follows:
- Collecting of blood in the neck
- Lung collapsing
- Bleeding problems from the stoma
- Entrapment of air in surrounding tissues
- Trach tube complications
- Oesophagus (food pipe) damage that hinders the swallowing of food
Certain patients are present in the high-risk category after a tracheostomy surgery. Smoking individuals, alcohol consumers, diabetic people, patients with immunocompromising diseases, patients with chronic diseases and other respiratory illnesses, etc., are at high-risk. Consumption of steroids is also a predisposition to risk after tracheostomy.
Tracheostomy Complications in the Elderly
Some complications occur later on after the tracheostomy and are listed as follows:
- Infection of the stoma area
- External scarring of the trachea
- Mucus build-up due to irritation
- Hole in the middle of the trachea and the food pipe (oesophagus)
Post Tracheostomy Care Procedure
The tracheostomy tube requires regular cleaning and periodic changes after tracheostomy decannulation. It helps to prevent issues of infection. A special machine that sucks in any obstructing materials from the throat must be connected. The use of saline solution at the tracheostomy site is important to diminish the drying of breathed air. There is an extra production of mucus in the throat, which must be loose. The breathed air is dry as it does not pass through the moist areas of the mouth or nose. It also leads to irritation and cough. Swallowing food will be a challenge after a tracheostomy procedure. Therefore nutrients are normally administered through IV. A feeding tube is another alternative to receiving food connected to the stomach. Speaking after the process will also be difficult and may need the use of a tracheostomy speaking valve. The doctor will refer the patient to either a speech therapist or provide techniques to help him speak faster.
How long can you live with a tracheostomy?
One year after a tracheostomy, the survival time is around 21 months. The survival rate is lower in patients above 60 years of age after a tracheostomy.
Can a person talk after a tracheostomy?
It is difficult to speak as the air breathed in passes out through the tracheostomy tube.
Is a tracheostomy better than a ventilator?
Patients on a ventilator for long or undetermined periods undergo a tracheostomy after ventilator surgery. There are some advantages of breathing through a tracheostomy tube over a ventilator for those patients who need Mechanical Ventilation (MV). Lesser occurrences of pneumonia, lower airway resistance, more comfort, better oral hygiene, and higher chances of being weaned from the MV are some benefits of a ventilator.
Why do COVID patients get a tracheostomy?
Since the Covid-19 virus spreads through the aerosol spread, avoid the non-invasive Mechanical Ventilation. Therefore invasive ventilation like tracheostomy is used for critically ill patients. Bag masking, nasal cannulas of the high-flow type, BiPAP, etc., are some of the ventilation procedures avoided, especially in Covid-19 infections. The advantages of undergoing a tracheostomy are less time in the ICU, decreased mortality rates, lesser need for sedation, lower chances of getting subglottic stenosis, etc.
How long can a person stay on a ventilator with COVID-19?
After undergoing a tracheostomy procedure in Covid-19 patients, there have been varying survival chances. Several patients only live for an average of ten days, and some live on ventilators for 118 days with positive recovery.
Is tracheostomy painful after that?
There will be a problem swallowing food for some days after a tracheostomy. The surgery happens after completely sedating the patient, and it is temporarily a painless procedure. Administered pain killers to the patient, and slowly, the patient will begin to learn to adjust after a couple of weeks.
How painful is a tracheostomy?
While performing tracheostomy surgery, either general or local anaesthesia is given to the patients to eliminate pain. The neck sores for a few days after the surgery, and it will be a troublesome experience to swallow for a few days.
What is the difference between a tracheostomy and a tracheotomy?
Tracheotomy is the cut made on the trachea to insert the tracheostomy tube. The process of inserting the tube within the stoma is called a tracheostomy. Both the words are used interchangeably.
How long do tracheostomy patients live?
Most tracheostomy patients live for 21 weeks after the surgery on average. Those patients with require Mechanical Ventilation for shorter time intervals are normally put on a ventilator, and longer periods on a ventilator increase the demand for a tracheostomy.